Ethnic disparity in maternal and infant mortality and its health-system determinants in Sichuan province, China, 2002–14: an observational study of cross-sectional data

Abstract

BackgroundThe disparity in maternal and child health is a global issue. This study aimed to examine how much disparity in maternal and infant mortality exists between ethnic minority and non-minority counties in Sichuan province, and to examine the health-system determinants of this disparity. MethodsIn this cross-sectional observational study, we obtained data for maternal mortality and infant mortality, and health system data on health-related human resources, institutions, and services, for 67 minority counties (based on an official classification that considered size of the minority population, number of townships with a high concentration of minority residence, and a history of minority residency) and 116 non-minority counties in Sichuan province for the years of 2002, 2006, 2010, and 2014. Data on maternal health-care service indicators were obtained from the Sichuan Maternal and Child Health Hospital; data on health human resources and health infrastructure were obtained from the Sichuan Health and Family Planning Statistic Information Centre; and data on socioeconomic and demographic characteristics were taken from the Sichuan Statistical Yearbook. A series of two-level Poisson regression models with different health system factors were fitted to identify the contributions of each factor to the inequality in maternal and infant mortality. FindingsMaternal mortality decreased in Sichuan province between 2002 and 2014 (from 65·4 deaths per 100 000 livebirths in 2002 to 18·6 deaths per 100 000 livebirths in 2014), as did infant mortality (from 19·2 to 5·1 deaths per 1000 livebirths), and the disparity in maternal mortality between minority and non-minority counties decreased (difference of 36·2 deaths per 100 000 livebirths in 2002, to 21·4 deaths per 100 000 livebirths in 2014), as did the disparity in infant mortality (from a difference of 12·21 to a difference of 2·37 deaths per 1000 livebirths). Between 2002 and 2014, health system indicators improved in minority counties and non-minority counties (eg, the proportion of hospital deliveries increased from 38% to 86% and from 78% to >99%, respectively). Lower maternal and infant mortality were associated with better socioeconomic conditions (maternal p=0·013; infant p=0·0005), more health-related human resources (maternal p=0·048; infant p=0·0002), and a higher proportion of maternal health-care services (maternal p<0·0001; infant p=0·006). Shorter travelling time to the nearest hospital was associated with lower infant mortality (p=0·006), but not lower maternal mortality (p=0·32). The proportion of deliveries in hospital explained 74·5% (95% CI 56·2–100) of the difference in maternal mortality between minority and non-minority counties. Hospital delivery and mean travelling time to the nearest hospital together explained 62·6% (95% CI 41·3–85·6) of the difference in infant mortality between minority and non-minority counties. InterpretationIncreasing the proportion of hospital deliveries in ethnic minority counties might narrow the disparity in maternal mortality by more than two-thirds. Similarly, increasing the proportion of hospital deliveries and the accessibility of health services in ethnic minority counties might further narrow the disparity in infant mortality by more than half the current level. FundingChina Medical Board (grant 12-106 to West China Research Centre for Rural Health Development) and the Countdown to 2015 for Maternal, Newborn, and Child Survival project (OPP1058954).